Form 3 Prostate Supplemental Questionnaire

ID # ___ - ___ - ___ ___ ___ ___ ___ ___

Supplemental Questionnaire for Prostate Study Participants

__________________________________________________________________________

OMB# 0925-XXXX

Expiration Date: XX / XX / XXXX

Attachment # 7

Name: Supplemental Case-Control Questionnaire

BURDEN STATEMENT:

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

PRIVACY STATEMENT:

Statement Of Privacy Act Applicability

You will be asked to participate in the research study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC57700”. The study will collect and use health information that can identify you. The authority to collect this information is under 42 USC 285 for the National Cancer Institute, National Institutes of Health. The Privacy Act from 1974 applies to the information collection.

Federal laws require researchers to protect the privacy of your health information. The collection of health information by this study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC57700” is covered by the Privacy Act and is in compliance with the Privacy Act System of Records Notice (SORN) # 09-25-0200 http://oma.od.nih.gov/ms/privacy/pa-files /0200, which covers clinical, basic, and population-based research studies of the National Cancer Institute and the National Institutes of Health

Table of Contents

Topic Page

A. Anthropometry 4

B. Medical History and Family Medical History 7

C. Sexual History 14

Identifier Sheet:

1. Date: __ __ / __ __ / __ __ __ __

2. Interviewer’s name:________________ Interviewer’s ID __ __

3. Hospital:________________________________ 

4. Doctor’s Name:___________________________ 

5. Patient’s Medical Record # ______________________

6. Patient’s Ethnicity ( )₁ Hispanic/Latino ( )₂ Not Hispanic/Latino

7. Patient’s Race ( )₁ White

( )₂ Black/African American

8. Time started: __ __:__ __ ( )₁ AM

( )₂ PM

8. Time ended: __ __:__ __ ( )₁ AM

( )₂ PM

OFFICE USE ONLY

Review

Reviewer’s initials: ___ ___ ___ Date reviewed: __ __ / __ __ / __ __ __ __

Coding and Editing

Coder’s Initials: ___ ___ ___ Date coded: __ __ / __ __ / __ __ __ __

Data Entry

First Entry  Initials: ___ ___ ___ Date Entered: __ __ / __ __ / __ __ __ __

Second Entry  Initials: ___ ___ ___ Date Entered: __ __ / __ __ / __ __ __ __

The interviewer will give a copy of this questionnaire to the person before the interview starts. The person should have the opportunity to read the questions while being interviewed. Section C is self-administered, and the person will be given 20 min to complete this section.

A. Anthropometry

1. When you were (AGE), how did your height compare with other boys/men your age? Were you much shorter, shorter, about the same, taller, or much taller than the average boy or man?

	Age	1. Much shorter (more than a foot)	2. Shorter (a foot or less)	3. About the same	4. Taller (a foot or less)	5. Much taller (more than a foot)
a.	9 or 10
b.	20-25

2. At what age did you reach your adult height?

__ __ __ years

3. When you were (AGE), how did your weight compare with other boys/men your age? Were you much thinner, thinner, about the same, heavier, or much heavier than the average boy or man?

	Age	1. Much thinner	2. Thinner	3. About the same	4. Heavier	5. Much heavier
a.	9 or 10
b.	20-25
c.	40-45
d.	Now, current age

4. When you were about 25 years old, about how much did you weigh?

__ __ __ lbs

5. Since you were 25 years old, what was the most you have ever weighed?

__ __ __ lbs

6. When you gain weight, where on your body do you mainly tend to add the weight?

( )₀ don’t gain weight

( )₁ around the waist and stomach

( )₂ around the hips and thighs

( )₃ around the chest and shoulders

( )₄ equally all over

( )₅ other (specify) ______________________________ 

7. During the past 6 months, have you lost 10 or more pounds?

( )₀ No (Skip to A. 10)

( )₁ Yes

8. If yes, how much weight did you lose?

( )₀ more than 40 pounds

( )₁ 21-40 pounds

( )₂ 10-20 pounds

9. Was your weight loss on purpose?

( )₀ No

( )₁ Yes

10. Interviewer: will ask.. I would now like to measure your waist circumference.

Waist circumference (cm)

First Second Difference Tolerance Third

|__|__|__|.|__| |__|__|__|.|__| |__|__|__|.|__| 2.0 |__|__|__|.|__|

11. Interviewer: will ask.. I would now like to measure your hip circumference.

Hip circumference (cm)

First Second Difference Tolerance Third

|__|__|__|.|__| |__|__|__|.|__| |__|__|__|.|__| 2.0 |__|__|__|.|__|

12. How would you describe your chest hair density?

( )₀ thick

( )₁ medium

( )₂ thin

( )₃ no hairs

13. Have you experienced any permanent hair loss from your scalp since you were

twenty years old?

( )₀ No (Skip to A. 15)

( )₁ Yes

14. If yes, at what age did the hair loss begin?

__ __ years

15. Interviewer: Please indicate hair thickness

( )₀ thick

( )₁ medium

( )₂ thin

( )₃ no hairs

16. Interviewer: Please indicate hair pattern on dome

( )₀ no evident loss

( )₁ some loss

( )₂ patterned baldness

( )₃ few hairs

( )₄ no hairs

Some loss Patterned baldness

17. Have you ever used any hair growth products?

( )₀ No

( )₁ Yes

18. Are you using a wig or toupee?

( )₀ No

( )₁ Yes

B. Medical History and Family Medical History

1. Are you now taking insulin?

( )₀ No (Skip to B. 4)

( )₁ Yes

2. At what age did you begin to take insulin? __ __ years

3. For what reason do you take insulin? ________________________ 

4. Are you now taking pills to lower you blood sugar? These are sometimes called oral agents or oral hypoglycemic agents?

( )₀ No (Skip to B. 7)

( )₁ Yes

5. At what age did you begin to take hypoglycemic agents? __ __ years

6. For what reason do you take hypoglycemic agents? ___________________ 

7.	Have you ever taken the following medication?	Yes/No	When did you start taking the medicine or drug? (Year)	If you stopped taking the medication or drug, when did you stop? (Year)	For how many years in total have you been taking the medication or drug?
a.	Proscar	( )0 No ( )1 Yes ( )2 Don’t know	__ __ __ __	__ __ __ __	___ ___
b.	Propecia	( )0 No ( )1 Yes ( )2 Don’t know	__ __ __ __	__ __ __ __	___ ___
c.	Viagra	( )0 No ( )1 Yes ( )2 Don’t know	__ __ __ __	__ __ __ __	___ ___
d.	Androgen supplements (such as DHEA, Androstenedione, Norandrostenedione)	( )0 No ( )1 Yes ( )2 Don’t know	__ __ __ __	__ __ __ __	___ ___
e.	Body-building or performance enhancing agents	( )0 No ( )1 Yes ( )2 Don’t know	__ __ __ __	__ __ __ __	___ ___
f.	Non-steroidal anti-inflammatory drugs (Advil, Aspirin, Motrin, Aleve, Piroxicam, Naproxen, Sulindac)	( )0 No ( )1 Yes ( )2 Don’t know	__ __ __ __ __ __ __ __ __	__ __ __ __	___ ___

8. During a typical night, how many times do you wake up to urinate?

( )₀ never (Skip to B. 10)

( )₁ once (Skip to B. 10)

( )₂ twice

( )₃ three times

( )₄ more than three times

9. How old were you when you first began waking to urinate more than once a night on

a regular basis?

___ ___ years

10. Were you ever treated by a doctor for a urinary tract infection since the age of 25?

( )₀ No (Skip to B. 12)

( )₁ Yes

11. How old were you when your doctor first told you that you had a urinary tract infection?

__ __ years

12. Have you had a vasectomy that is a sterilization operation for men?

( )₀ No (Skip to B. 14)

( )₁ Yes

13. How old were you when you had a vasectomy?

__ __ years

14. Are you circumcised?

( )₀ No (Skip to B. 16)

( )₁ Yes

15. At what age were you circumcised?

( )₁ newborn

( )₂ other (specify in years) _______

16. Did a doctor ever tell you that you had a problem with your prostate or a disorder of the prostate?

( )₀ No (Skip to B. 18)

( )₁ Yes

17.	Did a doctor ever tell you that you had:	Yes/No	How old were you when you were diagnosed?
a.	an enlarged prostate or benign prostatic hypertrophy	( )0 No ( )1 Yes ( )2 Don’t know	__ __
b.	an inflamed prostate or prostatitis	( )0 No ( )1 Yes ( )2 Don’t know	__ __
c.	some other problem or disorder related to the urinary tract (specify) ____________________ 	( )0 No ( )1 Yes ( )2 Don’t know	__ __

18. Have you ever had any prostate surgery?

( )₀ No (Skip to B. 21)

( )₁ Yes

19. How many prostate surgeries have you had? __________

20.	Year of last surgery	Hospital name	City	State
a.
b.
c.

21.	Did a doctor ever tell you that you had:	Yes/No	How old were you when you were first diagnosed?	How many times altogether have you had (disease)?
a.	Gonorrhea	( )0 No ( )1 Yes	__ __ __	__ __
b.	Syphilis	( )0 No ( )1 Yes	__ __ __	__ __
c.	Other venereal or sexually transmitted disease (Specify)___________	( )0 No ( )1 Yes	__ __ __	__ __
d.	Other venereal or sexually transmitted disease (Specify)___________	( )0 No ( )1 Yes	__ __ __	__ __
e.	Other venereal or sexually transmitted disease (Specify)___________	( )0 No ( )1 Yes	__ __ __	__ __
f.	Other venereal or sexually transmitted disease (Specify)___________	( )0 No ( )1 Yes	__ __ __	__ __

Family Medical History

22. Has anyone in your family that is related to you by blood, ever been told he had benign prostatic hypertrophy or an enlarged prostate? Include your sons, grandsons, father, paternal grandfather, maternal grandfather, great grandfathers, brothers, male cousins, and immediate uncles.

( )₀ No (Skip to B. 24)

( )₁ Yes

23. Which relative?	First name	How old were they when they were diagnosed?
a. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
b. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
c. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
d. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
e. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
f. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
g. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know

24. Has anyone in your family that is related to you by blood, ever been told he had an inflamed prostate or prostatitis? Include your sons, grandsons, father, paternal grandfather, maternal grandfather, great grandfathers, brothers, male cousins, and immediate uncles.

( )₀ No (Go to Sexual History Section C)

( )₁ Yes

25. Which relative?	First name	How old were they when they were diagnosed?
a. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
b. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
c. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
d. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
e. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
f. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
g. 		( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know

C. Sexual History

Section C is self-administered, and the person will be given 20 min to complete this section.

1. At what age did you experience puberty (voice change, growth of pubic hair)?

__ __ years

2. How many live-born children have you fathered? Do not include any stepchildren, foster children, or adopted children.

__ __ __ (If zero, skip to C. 4)

3. How old were you when your first child was born?

__ __ years

4. How old were you when you first had sexual intercourse?

__ __ years

5. Throughout your life, what is the total number of partners with whom you have had sexual intercourse?

( )₁ less than 5

( )₂ 5 to 9

( )₃ 10 to 19

( )₄ 20 to 39

( )₅ 40 or more

6. Have you ever tried to conceive a child for one year or more without success?

( )₀ No (Skip to C. 8)

( )₁ Yes

7. Did a doctor ever say that you had a problem that might be related to your difficulty in conceiving a child? If so, what was the problem? ____________________ 

9. If you think back to when you were (age group), and you think about the period of time in that decade when you had sexual intercourse, how often would you say you had sexual intercourse per year?	8. When you were (age group) with how many different partners did you have intercourse?
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your teens
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your 20s
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your 30s
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your 40s
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your 50s
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your 60s
_ _ times per ( ) month ( ) year	( )0 0 ( )1 1 ( )2 2 ( )3 3-4 ( )4 5-9 ( )5 10-19 ( )6 20-39 ( )7 40 or more	In your 70s

10. Do you usually use condoms (rubbers)?

( )₀ No

( )₁ Yes

11. Before one year ago, did you usually use condoms (rubbers)?

( )₀ No

( )₁ Yes

12. Not counting the past year, for how many years did you use condoms (rubbers)?

______________

YEARS

Thank you for your time! We greatly appreciate your participation in the study.

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